Spinal for knee replacement with underlying sciatica

[osoprop28]

Just wanted to get your opinions on this. Had a pt undergoing knee replacement, and we do ours with spinal. The lady was healthy except she had moderate sciatica pain, with MRI showing disc herniation, spinal stenosis, arthritis around L1-4 area.

My understanding is that you avoid neuraxial in these patients as it can exacerbate the condition.

My attending said studies have shown that spinals can only exacerbate the sciatica temporarily so it should be fine, but epidural is a definite no-no.

The pt ended up refusing anyway, but I was little confused since my literature search didn't really find the same outcome as my attending.

In your practices, would you just do GA or place neuraxial? And if neuraxial, does it matter epidural or spinal for the above pathology? I mean we place epidural in labor for pt with these conditions no?

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[Arch Guillotti]

Spinal.

 

[osoprop28]

Spinal.

What's the reasoning? Is it same as my attending where it only exacerbates it temporarily? And why not epidural?

 

[Psai]

Put some preservative free steroid in the spinal

 

[Mman]

I put spinals in those patients all the time. What I don't do is sciatic nerve blocks in patients with chronic sciatic pain.

 

[deleted126335]

There is no medical contraindication to spinal anesthesia in this patient. There is a concern that if her sciatica were to worsen Perioperatively, the spinal could be implicated. In short a general anesthetic is more of a clean getaway. Depending on the medicolegal environment in which you practice that is more than enough reason to pass on a spinal.

 

[deleted162650]

What's the reasoning? Is it same as my attending where it only exacerbates it temporarily? And why not epidural?

Because
A) more volume/pressure in the epidural space could potentially exacerbate the stenosis

And

B) an epidural is a ****ty surgical anesthetic

 

[osoprop28]

I put spinals in those patients all the time. What I don't do is sciatic nerve blocks in patients with chronic sciatic pain.

Thanks alot that's good to know. So in your experience it doesn't seem to worsen their symptoms or place them at any significant neurologic risk?

 

[deleted162650]

I would say it dramatically improves their symptoms for 2-3 hrs.

 

[deleted875186]

Neuraxial Blockade in Patients with Spinal Stenosis:... : Anesthesia & Analgesia

I’m not sure about your attending saying it will exacerbate the stenosis. However, nerve damage is probably not as rare as we believe with regional anesthesia, but overall still very small. I agree that GA completely avoids any perceived risk. We probably do spinals in elddeely patients with moderate stenosis that is unrecognized.

 

[okayplayer]

I would say it dramatically improves their symptoms for 2-3 hrs.

Hahahah you kill me dude

 

[deleted697535]

Whats the big deal? I love giving these ppl a GA. Spinals are a pain in the ass sometimes in this age group
Let her decline a spinal all she wants... LMA takes all of 10 seconds and dont have to deal with whingey patients/sedation/spinal wearing off bla bla bla

Theres very little real evidence a spinal is better than a GA anyway in TKR. Maybe DVT decr but the studies are all conflicting last time i checked

 

[kmurp]

What's the reasoning? Is it same as my attending where it only exacerbates it temporarily? And why not epidural?

Too much local when combined with the surgeon injected local potentially.

 

[coffeebythelake]

sciatica patients being put in exaggerated positions for surgery (e.g., high lithotomy) can exacerbate symptoms postop too..... fyi......

 

[deleted875186]

sciatica patients being put in exaggerated positions for surgery (e.g., high lithotomy) can exacerbate symptoms postop too..... fyi......

Yes but the anesthesia technique won’t be implicated.

 

[Hoya11]

Because
A) more volume/pressure in the epidural space could potentially exacerbate the stenosis

And

B) an epidural is a ****ty surgical anesthetic

Keep in mind that the treatment for her bulging disc is in fact an epidural injection, often with 5cc or so injected right at the closest point to the pathology, which often helps with the pain, not worsen it ...

I personally think that you can safely do a spinal or an epidural in this patient if needed, the bolus of local that you are giving spreads quite a distance throughout the posterior and anterior epidural space and up and down several levels. I think the spread of the local would be very unlikely IMO to build in one area, let alone her tightest area which should have the highest pressure and push it away.

If this was a woman requesting a labor epi with a known disc herniation and radicular symptoms, IMO her back pathology is not a contraindication to epidural